Department of Surgery, University of Florida College of Medicine/Jacksonville, FL 32209, USA.
J Pediatr Surg. 2010 Feb;45(2):310-3; discussion 313-4. doi: 10.1016/j.jpedsurg.2009.10.069.
Seven metrics of metabolic derangement were evaluated as contributors to clinical decision support for operative intervention in infants with suspected necrotizing enterocolitis (NEC).
Records of infants with suspected NEC without radiologic evidence of free air were queried for presence of 7 components of metabolic derangement (CMD), consisting of positive blood culture, acidosis, bandemia, thrombocytopenia, hyponatremia, hypotension, or neutropenia. Cases were stratified by clinical decision after each surgical evaluation as observation (OBS) or intervention (INT). Good outcome was defined as full enteric feeding by discharge and bad outcome as death or ongoing parenteral alimentation. Eleven infants undergoing operative intervention after an initial decision to observe were evaluated as matched pairs. Components of metabolic derangement/case and frequency of each CMD were determined for OBS and INT. Mann-Whitney U test was used to compare proportions of CMD in each group. Outcome was compared using chi(2). Observation was then stratified by outcome to determine whether 3 or more metabolic derangements warranting operative intervention would have changed initial clinical decision. The 11 matched cases were similarly analyzed using Wilcoxon-matched pairs.
Between March 2005 and July 2008, 35 infants with NEC received 53 surgical evaluations. A median of 1 CMD/case was defined in 32 instances of OBS. Surgical intervention was carried out in 19 infants with a median of 3 CMD/case. Mann-Whitney U test indicated significant difference in the frequencies of each CMD component in OBS vs INT (P = .04). Good outcome was achieved in 75% of OBS and 63% of INT (non-significant, NS). Analysis of OBS by outcome demonstrated a median 1 CMD/case of 25 with good outcome and 3 CMD/case in infants with bad outcome. Frequency of CMD was significantly higher in infants with bad outcome (P = .02). Wilcoxon-matched pair analysis of the 11 infants with paired evaluations demonstrated a similar distribution and frequency of CMD.
Progressive metabolic derangement of infants with NEC can be clinically tracked. The appearance of any 3 of these 7 metrics indicates timely operative intervention. Application of CMD trajectory to timing of surgical intervention may improve outcome and define the relationship between specific CMD and operative risk.
评估代谢紊乱的 7 项指标是否有助于为疑似坏死性小肠结肠炎 (NEC) 的婴儿提供临床决策支持以进行手术干预。
对没有游离气放射影像学证据的疑似 NEC 婴儿的记录进行了 7 项代谢紊乱 (CMD) 成分的检测，包括血培养阳性、酸中毒、血中出现中幼粒细胞、血小板减少症、低钠血症、低血压或中性粒细胞减少症。根据每次手术评估后的临床决策，将病例分为观察 (OBS) 或干预 (INT)。良好的结局定义为出院时完全肠内喂养，不良结局定义为死亡或持续肠外营养。对最初决定观察后进行手术干预的 11 名婴儿进行了配对分析。确定 OBS 和 INT 中代谢紊乱成分/病例和每种 CMD 的频率。采用 Mann-Whitney U 检验比较两组中 CMD 的比例。采用卡方检验比较结局。然后根据结局对观察进行分层，以确定是否存在 3 种或更多种需要手术干预的代谢紊乱会改变初始临床决策。对 11 对匹配病例也采用 Wilcoxon 匹配对进行了类似分析。
2005 年 3 月至 2008 年 7 月，35 名 NEC 患儿接受了 53 次手术评估。在 32 例 OBS 中，中位数为 1 CMD/病例。19 名患儿进行了手术干预，中位数为 3 CMD/病例。Mann-Whitney U 检验表明 OBS 和 INT 中各 CMD 成分的频率有显著差异 (P =.04)。OBS 的良好结局发生率为 75%，INT 为 63%（无显著差异，NS）。根据结局对 OBS 进行分析显示，良好结局的患儿中位数为 1 CMD/病例，25 例；不良结局的患儿中位数为 3 CMD/病例。不良结局患儿的 CMD 频率显著升高 (P =.02)。对 11 对配对评估的患儿进行 Wilcoxon 匹配对分析，显示出类似的 CMD 分布和频率。
NEC 患儿的代谢紊乱可以进行临床跟踪。这 7 项指标中的任何 3 项出现表明需要及时进行手术干预。CMD 轨迹的应用可能改善结局，并定义特定 CMD 与手术风险之间的关系。
